Foot and Ankle Injuries in Professional Soccer Players: Diagnosis, Treatment, and Expectations

Gender differences in foot and ankle sporting injuries: A systematic literature review

BACKGROUND

In response to the all-time high of female sports participation, there has been increasing scientific discourse and media interest in women's sporting injuries in recent years. In gender comparable sports the rate of foot and ankle injury for women is higher than for men. There are intrinsic and extrinsic factors which may explain this difference.

METHODS

A systematic literature search was performed according to the PRISMA guidelines of PubMed, Ovid EMBASE and OVID MEDLINE. Relevant key terms were used to narrow the scope of the search prior to screening. Case reports, review articles, paediatric patients, non foot and ankle injuries and combat sports were excluded. We used dual author, two pass screening to arrive at final included studies.

RESULTS

2510 articles were screened after duplicate exclusion. 104 were included in this literature review. We identified lack of reporting gender difference in the literature.We identified that females have higher frequency and severity of injury. We provide an overview of our current understanding of ankle ligament complex injuries, stress fractures, ostochondral lesions of the talus and Achilles tendon rupture. We expand on the evidence of two codes of football, soccer and Australian rules, as a "case study" of how injury patterns differ between genders in the same sport. We identify gender specific characteristics including severity, types of injury, predisposing risk factors, anatomy, endocrinology and biomechanics associated with injuries. Finally, we examine the effect of level of competition on female injury patterns.

CONCLUSIONS

There is a lack of scientific reporting of gender differences of foot and ankle injuries. Female athletes suffer foot and ankle injuries at higher rates and with greater severity compared to males. This is an under-reported, yet important area of orthopaedics and sports medicine to understand, and hence reduce the injury burden for female athletes.

Assessing Functional Ankle Instability in Sport: A Critical Review and Bibliometric Analysis

Functional Ankle Instability (FAI) is the subject of extensive research in sports and other environments. Given the importance of accurately measuring this latent construct, it is imperative to carry out a careful assessment of the available tools. In this context, the aim of this review was to take an in-depth look at the six most cited measurement tools to assess FAI, with a specific focus on patient-reported outcome measures related to ankle and foot. Four electronic databases (Web of Science, Scopus, Pubmed, and SportDiscus) were searched (up to November 2022) to identify the six most cited questionnaires for assessing FAI. Our analysis showed that the most cited questionnaires are the following: the Lower Extremity Functional Scale (LEFS), the Foot Function Index (FFI), the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the Olerud and Molander Ankle Score (OMAS), and the Cumberland Ankle Instability Tool (CAIT). Each questionnaire was thoroughly assessed and discussed in three sections: Development, Reliability, and Summaries. In addition, bibliometric data were calculated to analyze the relevance of each questionnaire. Despite variations in terms of validity and reliability, conceptualization, structure, and usefulness, the six questionnaires proved to be robust from a psychometric point of view, being widely supported in the literature. The bibliometric analyses suggested that the FAOS ranks first and the FFI ranks sixth in the weighted average of the impact factors of their original publications.

The Antigravity Treadmill as a Postoperative and Injury Rehabilitation Tool: Reduction in Contact Forces and Muscle Activity With Reduced Weight Running

OBJECTIVE

To investigate the effects of reduced weight running on the antigravity (AG) treadmill on maintenance of normal muscle activation and reduction of plantar forces in healthy subjects.

DESIGN

Descriptive laboratory study.

SETTING

Clinical sports medicine center.

PARTICIPANTS

Twenty healthy subjects (10 male and 10 female) aged 18 to 29 years.

INDEPENDENT VARIABLES

Subjects running at 6.5 miles per hour on a standard treadmill and on the AG treadmill at 100%, 90%, 80%, 70%, 60%, and 50% of bodyweight levels.

MAIN OUTCOME MEASURES

Dynamic plantar loading data were recorded using pressure insoles. Surface electromyography electrodes with imbedded accelerometers were used to estimate timing and magnitude of muscle activity, stride length, and cadence.

RESULTS

There was a significant, sequential reduction in peak pressure, maximum force, and force time integral (FTI) with decreasing bodyweight. A 50% bodyweight reduction resulted in a 51% reduction in maximum force and a 59% reduction in FTI in the heel, as compared with 19% to 28% at the metatarsal heads. There was reduced contact area in the heel and midfoot at and below 70% BW. Lower limb muscle activity decreases with reduced bodyweight while maintain normal muscle recruitment timing.

CONCLUSIONS

The AG treadmill provides a reduction in loading forces while maintaining normal muscle recruitment patterns. Decreased BW running preferentially unloads the hindfoot. The AG treadmill can be an effective rehabilitation tool following foot or ankle injury and may prove superior to other limited weight-bearing methods.

Does the Position of the Ankle Matter During the Single Gluteal Bridge in Futsal Players? An Electromyographic Analysis

CONTEXT

The aim of this study was to analyze the muscle activity of the hamstring muscles and the lateral gastrocnemius during different variants of the single-leg bridge (SLB) in futsal players.

DESIGN

Cross-sectional study.

METHODS

Twenty-two futsal players (age = 24.8 [3.9] y) volunteered to participate in this study. The participants performed 3 variations of the SLB with the knee flexed at 45°. The first position was performed with the ankle in plantar position with flat support, the second with the ankle in dorsiflexion (DF) with heel support, and the third with the ankle in DF and external rotation (ER) with heel support. The Wilcoxon rank-sum test assessed the difference between variables for samples with the rank-biserial correlation effect size. Spearman correlation coefficients were used to examine the associations of the percentage maximal voluntary isometric contraction for each muscle with peak force and rate of force development with 3 different variances of the SLB.

RESULTS

The variation of ankle DF and ER with heel support generated higher muscle activity in BF in concentric (P < .01, effect size [ES] = -0.613); isometric (P < .042, ES = -0.494); and eccentric (P < .005, ES = -0.668) contraction than ankle DF with heel support. In contrast, the variation of ankle DF and ER with heel support generated fewer muscle activity in lateral gastrocnemius in concentric (P < .001, ES = 0.779); isometric (P < .003, ES = 0.708); and eccentric (P < .014, ES = 0.589) contraction than ankle DF with heel support.

CONCLUSIONS

The position of DF and ER was the best position in SLB to train the BF. It could be convenient to start rehabilitation of the BF with flat foot postition or ankle in DF with heel support and progress with the position of the ankle in DF and ER with heel support.

Patterns of ankle injury in soccer: MRI clues to traumatic mechanism

Understanding the traumatic mechanisms of ankle injuries in soccer is crucial for an accurate and complete MRI diagnosis. Many ankle injuries share universal mechanisms seen in other athletic activities, but certain patterns are found to be more specific and relatively unique to soccer. Ankle impingement syndromes encountered in soccer encompass a spectrum of disorders that include anterior and posterior impingement categories, with anterior impingement representing pathology relatively specific to soccer. Lateral ligamentous sprains are one of the most common injuries; however, there is a higher rate of injuries to the medial structures in soccer as compared to other sports. Ankle fractures are uncommon in soccer while bone contusions and chondral and osteochondral injuries frequently accompany ligamentous sprains. Tendon abnormalities in soccer most commonly result from overuse injuries and typically affect peroneal tendons, posterior and anterior tibialis tendons, and Achilles tendon. Acute Achilles tendon ruptures occur in both recreational players and elite soccer athletes. Tibialis anterior friction syndrome may mimic tibial stress fractures. Long-term sequelae of acute traumatic and chronic overuse ankle injuries in professional soccer players manifest as ankle osteoarthritis that is more prevalent compared to not only the general population, but also to former elite athletes from other sports. This article examines the most common and specific injuries in soccer in order of their frequency.

Alterations in Cortical Activation among Soccer Athletes with Chronic Ankle Instability during Drop-Jump Landing: A Preliminary Study

Background: Chronic ankle instability (CAI) is a common peripheral joint injury and there is still no consensus on the mechanisms. It is necessary to investigate electrocortical parameters to provide clinical insight into the functional alterations of brain activity after an ankle sprain, which would greatly affect the implementation of rehabilitation plans. The purpose of this study was to assess cortical activation characteristics during drop-jump landing among soccer athletes with CAI. Methods: A total of 24 participants performed the drop-jump landing task on a force platform while wearing a 64-channel EEG system. The differences of power spectral density (PSD) in theta and alpha (alpha-1 and alpha-2) bands were analyzed between two groups (CAI vs. CON) and between two limbs (injured vs. healthy). Results: CAI participants demonstrated significantly higher theta power at the frontal electrode than that in healthy control individuals (F(1,22) = 7.726, p = 0.011, η2p = 0.260). No difference in parietal alpha-1 and alpha-2 power was found between groups (alpha-1: F(1,22) = 0.297, p = 0.591, η2p = 0.013; alpha-2: F(1,22) = 0.118, p = 0.734, η2p = 0.005). No limb differences were presented for any frequency band in selected cortical areas (alpha-1: F(1,22) = 0.149, p = 0.703, η2p = 0.007; alpha-2: F(1,22) = 0.166, p = 0.688, η2p = 0.007; theta: F(1,22) = 2.256, p = 0.147, η2p = 0.093). Conclusions: Theta power at the frontal cortex was higher in soccer athletes with CAI during drop-jump landing. Differences in cortical activation provided evidence for an altered neural mechanism of postural control among soccer athletes with CAI.

Return to Play and Player Performance After Foot Fracture in UEFA Soccer Players

Background:

There is a paucity of information on rate and time to return to play (RTP) in elite-level soccer players who have sustained foot fractures.

Purpose:

To (1) determine the rate and timing of RTP after foot fracture (eg, tarsal, metatarsal, or phalangeal), (2) investigate foot fracture reinjury incidence after RTP, and (3) evaluate performance after foot fracture as compared with matched, uninjured controls.

Study Design:

Descriptive epidemiology study.

Methods:

Athletes sustaining foot fractures were identified across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2016. Injured athletes were matched to controls (1:1) using demographic characteristics and performance metrics from 1 season before injury. The authors recorded RTP rate, reinjury incidence, player characteristics associated with RTP within 2 seasons of injury, player availability, field time, and performance metrics during the 4 seasons after injury.

Results:

A total of 192 elite soccer players sustaining a foot fracture were identified; 40 players (20.8%) underwent operative treatment. Athletes missed an average of 69.41 ± 59.43 days and 5.15 ± 23.28 games. In the 4 seasons after injury, 80% of players returned to play, with 72% returning to play within 1 season of injury. Nine players (5%) sustained a subsequent foot fracture. Athletes with a foot fracture demonstrated significantly longer league retention compared with uninjured controls (P < .001). Elite soccer players older than 30 years of age were less likely to RTP (odds ratio, 0.67; P = .002), whereas career experience, field position, and baseline performance showed no significant association with RTP rates. Injured athletes demonstrated similar performance to controls during the 4 years after injury, and there were no position-dependent differences on subgroup analysis. The players who underwent operative treatment had more assists per 90 minutes and more team points per game during the first season after injury compared with athletes treated nonoperatively.

Conclusion:

Foot fractures in elite soccer players resulted in moderate loss of play time (69.41 days). RTP rates were high at 80%, although players older than 30 years of age were less likely to RTP. On RTP, athletes who sustained a foot fracture maintained performance similar to preinjury levels and to uninjured controls.

Physical exercises for preventing injuries among adult male football players: A systematic review

BACKGROUND

Football is the most practised sport in the world and is associated with the risk of injuries in the players. Some studies have been published that identify injury prevention programs, but there is no review of the full body of evidence on injury prevention programs for use by football coaches. The aim of this article was to carry out a systematic review of published studies on injury prevention programs for adult male footballers, identify points of common understanding and establish recommendations that should be considered in the design of injury prevention strategies.

METHODS

PubMed and EMBASE databases were used to identify relevant published articles using the following keywords: "soccer" AND "injury" AND "prevention".

RESULTS

A total of 2512 studies were identified initially, but only 11 studies met the inclusion criteria, and their outcomes are presented. Results revealed that injury prevention programs in football have focused on strength training, proprioceptive training, multicomponent programs (balance, core stability, and functional strength and mobility), and warm-up programs.

CONCLUSION

Based on results from the studies analyzed, football players can lower the incidence of match and training injuries by participating in dynamic warm-up programs that include preventive exercises before games or during training sessions, and by adding strength, balance, and mobility training to the training sessions.

Quantitative evaluation of ankle cartilage in asymptomatic adolescent football players after season by T2-mapping magnetic resonance imaging

BACKGROUND

Ankle sprain affects the structure and function of ankle cartilage. However, it is not clear whether the daily training and competition affect the ankle cartilage without acute injury. Changes in ankle cartilage without injury may influence future strategies to protect ankle function in athletes. This study aimed to evaluate whether the composition of ankle cartilage significantly altered in asymptomatic adolescent football players after a whole season of training and competition using T2-mapping magnetic resonance imaging (MRI).

MATERIALS AND METHODS

12 local club's U17 asymptomatic adolescent football players without abnormalities in routine MRI were included. Routine and T2-mapping MRI were performed to measure the cartilage thickness of tibiotalar joint (TT) and posterior subtalar joint (pST) and T2 values in pre- and post-seasons. All of them took the right side as dominant foot.

RESULTS

In the pre- and post-seasons, cartilage T2 values in TT (talus side) and pST (calcaneus side) were higher than that of TT (tibial side) and pST (talus side) (all p < 0.05), which was caused by magic angle effect and gravity load. No statistically significant differences in thickness after season in the other cartilages of ankle were found compared with that before the season (all p > 0.05). However, T2 values of TT (tibial side and talus side) cartilage in the dominant foot were significantly reduced after season (p = 0.008; p = 0.034). These results indicate that the microstructure of articular cartilage changes in the joints with greater mobility, although no trauma occurred and the gross morphology of cartilage did not change.

CONCLUSION

Changes in the T2 values of tibiotalar joint cartilage in the dominant foot of healthy young athletes before and after the season suggest that the microstructure of cartilage had changed during sports even without injury. This finding suggests that the dominant ankle joint should be protected during football to delay degeneration of the articular cartilage.

Playing surface traction influences movement strategies during a sidestep cutting task in futsal: implications for ankle performance and sprain injury risk

This descriptive laboratory crossover trial study examined the intervention of high friction synthetic vs lower friction natural sport surfaces on the ankle joint biomechanics in a sidestep cutting task. Twenty-nine male futsal players performed 5 trials of sidestep cutting task in a laboratory, recorded by an 18-camera motion capture system to obtain the ankle joint orientation, velocity and moment. Utilised friction was obtained by the peak ratio of the horizontal to vertical ground reaction force during the stance. Repeated measures (MANOVA) suggested a significant effect of the playing surface and post hoc paired t-tests revealed significantly higher utilised coefficient of friction, higher peak plantarflexion angle, lower peak eversion angle, higher peak inversion velocity, lower peak inversion moment and higher peak internal rotation moment. In performing a sidestep cutting task, futsal players demonstrated higher utilised ground friction when available friction from the playing surface was higher, resulting in higher peak inversion velocity and higher peak internal rotation moment, which may make the ankle joint more prone to sprain injury. Floorings for futsal should have an adequate coefficient of friction for agility and avoidance of the risk of slipping. Increasing the coefficient of friction may not only enhance performance but also endanger the ankle joint.

Ankle Injuries in Soccer Players: A Narrative Review

Soccer is one of the most popular sport, with many describing it as the "king of sports." In recent years, increased global participation in soccer has led to an inevitable increase in injury rates, especially in the lower extremities. Consequently, there is an increase in the epidemiology of soccer injuries, both in professionals and amateur athletes. The cause of an injury is multifactorial and depends on psychosocial, predisposing, intrinsic, and extrinsic factors. Also, contact with another player and non-contact injuries seem to be the most widespread mechanisms of injuries. The most common injuries recorded in soccer are ankle sprains and hamstrings injuries. More specifically, many studies have shown a correlation between the previous injury in lower extremities, weakness of abductors muscle, and psychosocial factors with the ankle sprain. Additionally, according to study results, injuries in adult men, adolescent men, and women during a match are higher than injuries during training. This narrative review aims to record the epidemiology of ankle injuries, risk factors, and the relationship between circadian rhythm, sleep, and injuries.

Asymptomatic Degenerative Changes in the Lumbar Spine Among Professional Soccer Players

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

The aim of this study was to evaluate the actual prevalence of degenerative spinal changes and their association with age in a cohort of professional soccer players.

SUMMARY OF BACKGROUND DATA

Presently, there are data that athletes have more degenerative changes than nonathletes; however, the research examining the prevalence of degenerative spinal conditions among professional elite soccer players is scarce.

METHODS

Professional male soccer players were included in the study (n = 40, average age 26,6 ± 4,5 years, average height 18 ± 0.07 m, weight 76.7 ± 7.1 kg). Lumbosacral spine MRI scanning at the L1-S1 level has been performed. Two radiologists with at least 7 years of experience of working with athletes evaluated all images independently of each other.

RESULTS

92.5% (n = 37) of soccer players had ≥1 spinal degenerative condition. Thirty-five percent (n = 14) of players had three to five, and 50% (n = 20) had six or more conditions. The average age of players who had six or more conditions was significantly higher than those who had zero to five or three to five conditions-28.1 ± 4.8 years versus 25.1 ± 3.6 years (P = 0.029), and 24.8 ± 3.6 years, respectively.Kruskal-Wallis test has shown no association between the number of degenerative conditions and weight (P = 0.98) as well as body mass index (P = 0.99). The age was associated with degenerative changes (P = 0.008).Disc desiccation was the most common pathologic condition, which was found in 82.5% of athletes. Facet joint arthropathy and spondylosis were present in 70, and 50% of the studied lumbar spine MRI scans, respectively. The spondylolysis prevalence of 20% was noted.

CONCLUSION

Elite professional soccer players demonstrate a high prevalence of asymptomatic degenerative lumbar spinal degenerative changes, which are significantly associated with age. These conditions might lead to the development of symptomatic lower back pain, given the high-intensity exercise required in professional soccer. It is presently unclear what measures might be applied for the primary prevention of these degenerative spinal conditions.Level of Evidence: 4.

The Federated Practice of Soccer Influences Hamstring Flexibility in Healthy Adolescents: Role of Age and Weight Status

The aim of this study was to compare the hamstring flexibility between federated soccer and non-federated adolescents, and also to evaluate the effect of age and weight status on hamstring flexibility. The participants were 234 students (11–18 years old) divided into: (i) G1: non-federated (n = 127), and (ii) G2: federated in soccer (n = 107). The deep flexion of the trunk (DF) test and the sit and reach test (SRT) were performed. G2 showed higher values for the DF and SRT compared to G1 (p < 0.05). Both flexibility tests correlated positively (r = 0.4, p < 0.001). Body mass index (BMI) was negatively correlated with the DF test (r = −0.3, p < 0.001), but not with the SRT. Divided by BMI, the underweight and normal weight groups had higher scores in the DF test compared with the overweight and obese groups (p < 0.001). BMI was negatively correlated with hamstring flexibility. Federated soccer students present higher scores of hamstring flexibility.